Bernard J. Wolfson
The number of people with symptoms of depression and anxiety has nearly quadrupled during the covid pandemic, which has made it even more maddeningly difficult to get timely mental health care, even if you have good insurance.
A California law signed Oct. 8 by Gov. Gavin Newsom could help. It requires that mental health and substance abuse patients be offered return appointments no more than 10 days after a previous session, unless their provider OKs less frequent visits.
Current insurance regulations already require giving patients an initial mental health visit no more than 10 days after they request it. But there’s been nothing on the books specifically about follow-up care until now.
The law doesn’t take effect until July, which lawmakers said will give health plans time to comply — mainly by hiring or contracting with more therapists. Proponents say that, with effective enforcement, the new law will help a lot of people get the care they need.
The law, SB 221, “will ensure that people can actually use their insurance to get mental health treatment,” says Sen. Scott Wiener (D-San Francisco), the law’s author. “For far too long, health plans have frequently made people wait long periods of time to get mental health appointments, which undermines their care.”
If you are not getting the care you need, there are already ways you can seek redress. When the law takes effect in eight months, it will strengthen your hand. More on that in a moment.
There are two competing explanations for why it’s so hard to get consistent mental health care. Insurers say there’s a shortage of therapists. Therapists say insurers are too cheap to pay them adequately. Many therapists decline to join insurance networks and set their own fees, which a lot of people can’t afford.
The National Union of Healthcare Workers, which sponsored the legislation, has been particularly critical of Kaiser Permanente, the state’s largest commercial health insurer, for its well-publicized mental health care deficiencies.
Kaiser Permanente, with over 9 million members in California, was fined $4 million by state regulators in 2013 for failure to provide timely mental health care. It was cited twice after that for failure to resolve the problems.
Former and current KP therapists say the managed-care giant has addressed the complaint by trying to ensure that members seeking mental health treatment get an initial appointment quickly. But that has only made it harder for those patients to get subsequent sessions, the therapists say.
“Any available appointment would be given to a person needing to initiate services,” says Susan Whitney, a marriage and family therapist who worked for Kaiser Permanente in Bakersfield for 18 years before leaving the organization in September. “Our schedules would be fully booked for six to eight weeks — so follow-up appointments were difficult to make, to say the least.”
The American Psychological Association recommends weekly therapy for people with depression and twice weekly for post-traumatic stress disorder. In a letter to California’s Department of Managed Health Care last year, the association said the long waits for follow-up care reported by KP patients and therapists “fall far below what is appropriate care for most patients.”
Because of the shortage of available therapists, Kaiser Permanente often refers its members to an outside network of providers for mental health treatment. But members, therapists and public officials say those networks often fail to deliver.
Maya Polon, a KP member in Sacramento, began feeling emotionally frayed in March, after caring for her terminally ill grandmother. She tried to get help through Kaiser but had to make numerous calls and kept getting conflicting information about how to get care.
Finally, after more than a month, a Kaiser Permanente therapist told Polon, 27, that her depression, anxiety and panic attacks qualified her for a year of therapy. But if she wanted to do it through Kaiser, it would take six months to get her first appointment.
KP referred her to an outside mental health contractor, Beacon Health Options, which took two weeks to send her a list of therapists. She called all 20 providers on the list, during breaks in her workday, and left messages.
“As someone with anxiety and who suffers from depression, having to actively sit down and call people who are over and over again telling you, ‘Oh, I’m not actually taking new patients,’ is an overwhelmingly defeating process,” Polon says. “I walked away from that thinking, ‘Do I even want to do therapy if this is what I am going to have to go through to even get there?’”
She ended up seeing the one therapist who had space for her, but she wasn’t contracted with Beacon. Polon had to wrangle with Kaiser Permanente for months over the paperwork.
In June, San Diego’s city attorney, Mara Elliott, sued Kaiser over what she termed “ghost networks” that “falsely describe the breadth of an insurer’s provider network, promising consumers access to health care that in reality is unavailable under the plan.” Elliott sued Molina Healthcare and Health Net on similar grounds.
Dr. Yener Balan, vice president of behavioral health and specialty services at Kaiser Permanente in Northern California, says the organization could do better, but claims that it meets the follow-up appointment recommendations of its mental health clinicians 84% of the time — a figure hotly contested by union officials and therapists.
Balan says SB 221’s July implementation date is helpful, “given the shortage of mental health clinicians faced by all health care organizations.”
Critics of the health insurance industry question whether a shortage of therapists is the main problem. Wiener says health plans aren’t paying mental health practitioners enough to join their networks.
A 2019 report by the California Future Health Workforce Commission projected that within a decade there would be 41% fewer psychiatrists than needed and 11% fewer psychologists, marriage and family therapists, and other mental health workers.
But a report the same year by the state Legislative Analyst’s Office said the number of graduates of mental health programs had grown significantly — although there was, it reported, a shortage of psychiatrists.
The Department of Managed Health Care, which regulates health plans covering a large majority of Californians, will monitor compliance with the new law and investigate consumer complaints, says Rachel Arrezola, an agency spokesperson.
What You Can Do
If you believe your health plan is shortchanging you on mental health treatment, you don’t have to wait for the new law. You can challenge your insurer under existing regulations. Once the law takes effect, however, it will offer additional ballast for any challenges and allow regulators to pursue health plans for violations.
To contest a lack of coverage, you must first appeal directly to your health plan. If you are in a private plan, you must file the appeal within six months of care being denied. The insurer must decide on your appeal within 30 days.
If you don’t get a satisfactory decision, take your case to the agency that regulates your insurer for an independent review. And if there’s an urgent health risk, you don’t need to wait 30 days. Contact your regulator immediately.
To find out what agency that is, call the customer service line of your health plan. If it is the Department of Managed Health Care, you can request an independent review by calling 888-466-2219 or logging on to HealthHelp.ca.gov. If your regulator is the California Department of Insurance, call 800-927-4357.
If you are in managed-care Medi-Cal and your plan is regulated by the Department of Managed Health Care, you can ask that department for an independent review. You can also seek a “fair hearing” through the state, as can any Medi-Cal beneficiary, by going online or calling 855-795-0634.
Of course, all this takes time and effort. But if the delay is making it impossible for you to get treatment, it may be worth it.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of LowerMyRx.